Healthcare Provider Details

I. General information

NPI: 1952300832
Provider Name (Legal Business Name): STEPHEN BRENT CLARK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 07/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8390 NORTH HWY 27
ROCK SPRING GA
30739-2103
US

IV. Provider business mailing address

8390 NORTH HWY 27
ROCK SPRING GA
30739-2103
US

V. Phone/Fax

Practice location:
  • Phone: 706-375-1720
  • Fax: 706-375-1729
Mailing address:
  • Phone: 706-375-1720
  • Fax: 706-375-1729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD002478
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002352
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: